Speech Improves After Frenuloplasty in Children With Ankyloglossia Yasuo, Ito1) Toshimitsu Shimizu 2), Tomomi Nakamura 2), Chie Takatama 2) Division of Pediatric Surgery 1) and Division of Speech Therapy 2) International University of Health and Welfare Atami Hospital, Japan

Ankyloglossia Presenting symptoms： Latching problems 20 patients Thirty one patients with ankyloglossia visited our clinic from September 2010 through August 2012. Presenting symptoms： Latching problems 20 patients Speech problems 7 patients Tongue deformity 5 patients

Subjects and Methods Five children with speech problems were evaluated for their misarticulations before and after frenuloplasty. Severity of ankyloglossia was assessed by an assessment score for children over 1 year old. (modified from the Hezelbaker assessment tool )

Assessment score for ankyloglossia in children over 1 year old. 1) Attachment of lingual frenulum to tongue 2: > 1 cm from tip 1: > 6 mm and < 1 cm from tip 0: < 5 mm from tip 2) Attachment of lingual frenulum to oral floor 2: Attached to floor of mouth 1: Attached to lower ridge 0: Attached to upper ridge 3) Appearance of tongue when protruded 2: Round 1: Slight cleft in tip 0: Heart-shaped 4) Extension of tongue 2: Tip over upper lip 1: Tip over lower lip 0: Neither of the above 5) Speech for age 2: not disturbed 1: a little disturbed 0: markedly disturbed Total score： 1-3: Appearance scores.　 4 and 5: Functional scores

Details of patients who underwent surgery for articulation disorders. Age (y/o) Sex Severity score 　　　　　　　 History Operation 1 5 male ５ Attending speech training class, Inherited frenuloplasty 2 8 female ７ Attending speech training class Fren uloplasty 3 ６ Pointed out by a nursery teacher 4 ４ Pointed out by a local physician frenotomy 6

Articulation test (1) (From the guidelines of Japan Society of Logopedics and Phoniatrics) Speech articulation test consists of 50 pictures of common Japanese words with 2-3 syllables. Patients were asked to pronounce what the picture card showed.

Articulation test (2) Word production accuracy and intelligibility were assessed by counting the number of errors. Misarticulations of substitution, omission, and distortion were checked using international phonetic alphabets on a test sheet.

Types of misarticulation Definition of Misarticulation 　Example　 Substitution Replacement of a sound with another sound “wed” for “red, “dut,” for “duck” Omission No production of a sound in a word “pay ” for “play” Distortion Production of a sound in an unfamiliar manner (non-typical sound) “pencil” (nasalized p sound more like “m”encil), ｌａｔｅｒａｌ “s” sound

Postoperative evaluation Number of substitutions and the sounds expressed according to international phonetic alphabets. Patient Preoperative evaluation Postoperative evaluation 1 month 3-4 months 1-2 years 1 3 (s, dz, ts) 0 (-) 0 (- ) - 2 3 6 (k, g, ɲ, ŋ, ʧ, gj) 3 (k,g,ŋ) 1 (k) 1 (s) 4 5 (s, ʤ, ts, ʃ, ɾ) 4 (s, ts, ʃ, ɾ) 5 5 (s, dz, ts, ʃ, ɾ) 2 (ʃ, ɾ) 2 (d, ɾ) Total 19 10 7

Number of substitutions before and after frenuloplasty

Postoperative evaluation Number of omissions and the sounds expressed according to international phonetic alphabets Patient Preoperative evaluation Postoperative evaluation 1 month 3-4 months 1-2 years 1 1 (ɾ) 0 (-) - 2 3 4 2 (t, ɾ ) 1 (t) 5 Total

Postoperative evaluation Number of distortions and the sounds expressed according to international phonetic alphabets. Patient Preoperative evaluation Postoperative evaluation 1 month 3-4 months 1-2 years 1 2 (s, ɾ) 0 (-) - 2 3 (ʧ, ʤ, ʃ) 2 (ʧ, s) 8 (ki, kjm, gi, ɲi, ʃi, ʧo, ʧi, ri) 3 5 (s, ʧ, dz, ts, ɾ) 4 (dz, s, ɾ, k) 4 (dz, ts, s, ɾ) 4 1 (ɾ) 5 2 (ki, gi) 2 (ki, çi ) 1 (ki) 1 (ʧi) Total 13 9 8 11

Number of distortions before and after frenuloplasty

Summary of Misarticulations before and after frenuloplasty Type Preoperation No. of Cases (No. of Errors) Postoperation 1 month 3-4 months 1-2 years Substitution 4　 (19) 3　(10) 3　 (7) 1 (1) Omission 4　 (5) 3　 (3) 2　 (2) １ (1) Distorsion 5　 (13) 4　 (9) 4 　 (8) 3 (11)

Operative Outcomes of Speech Disorders Associated Wth Ankyloglossia Author （year） No. of cases Operative method 　　　Improvement ratio （assessment method, follow-up period） Ito S (1988) 13 Not described 84.6％ 　(11/13) (articulation test, 2 weeks-7months) Messner AH (2002) 11 horizontal-to-vertical (H-V) frenuloplasty 82％　 (9/11 ) score （5 points maximum） 3.4 → 4.2　 （ｐ<0.01) （parent questionnaires, 3-6 months) Heller J (2005) 16 z-frenuloplasty 11cases H-V frenuloplasty 5 cases z-frenuloplasty : improvement >2 grades 91% (No improvement 9%) H-V frenuloplasty: improvement of 1 grade 40% (No improvement 60%)　　　 （4 grade scale, >10 months)

Conclusions Articulation disorders in children with ankyloglossia were improved by frenuloplasty. Phonetical and philological studies were effective to evaluate articulation disorders. Substitution and omission improved relatively early after frenuloplasty and progressed to distortion. The number of distortions did not significantly decrease and tended to remain a defective speaking habit. Postoperative speech training by a speech pathologist would be necessary for older patients who acquire abnormal speaking habits.